NEW APPROACHES TO LIPID MODIFICATION

David Preiss MRC Population Health Research Unit Clinical Trial Service Unit University of Oxford

Nuffield Department of Clinical Trial Service Unit & Population Health Epidemiological Studies Unit Content

• Background • PCSK9 inhibition – Monoclonal antibodies – Small interfering RNA • CETP inhibition • Final word – statin therapy Lipoprotein structure The various circulating lipoproteins Lipids and their association with coronary disease

13,000 incident coronary events

Non HDL- HDL- Triglycerides cholesterol cholesterol 3.5 3.0

2.5

2.0

1.5 Hazard ratio (95% CI) ratio Hazard 1.0

3.0 3.5 4.0 4.5 5.0 5.5 0.8 1.0 1.2 1.4 1.6 1.8 1.0 2.0 3.0 Mean lipid level (mmol/L)

Adjusted for age and sex only Further adjusted for non-lipid and lipid factors

Sarwar et al. ERFC, JAMA 2009 Evidence of causality – cardiovascular disease

Observational Monogenic Randomized Polymorphisms (association) disease trials

lowering PCSK9 LDL     cholesterol raising CETP HDL     cholesterol lowering triglyceride  -  (?) Expected reduction in MAJOR VASCULAR EVENT risk from lowering LDL-C with STATIN therapy

Control 20

22% relative risk Statin reduction per mmol/L

15 15% relative risk More statin reduction per 0.5 mmol/L 10 Combined evidence: Or: 34% relative risk reduction ~40% relative risk reduction per 1.5 mmol/L vascular % event, vascular per 2 mmol/L (0.78 x 0.78) (since 0.78 x 0.85 = 0.66) 5 Five Five year risk ofa major 0

0 1 2 3 4 5 LDL cholesterol, mmol/L PCSK9 – an attractive CVD target

• Proprotein convertase subtilisin/kexin type 9 • Circulating protein largely produced in the liver • Intimately involved in LDL receptor turnover – Higher PCSK9 = reduced LDL expression = higher LDL-c  – Lower PCSK9 = increased LDL expression = lower LDL-c  • Seminal genetic studies1-4: – Gain of function mutations = rare type of FH – Loss of function mutations = reduced CVD; no clinical disadvantage – PCSK9 polymorphisms

1. Abifadel M, Nat Gen 2003, 34:154–156 2. Cohen JC, NEJM 2006, 354:1264–1272 3. Benn M, JACC 2010, 55:2833–2842 4. Zhao Z, Am J Hum Gen 2006, 79:514–523 PCSK9 and the hepatic LDL receptor Approaches to reducing PCSK9 (and LDL-c)

• Monoclonal antibodies

– Evolocumab PCSK9 inhibitor – Alirocumab (act in circulation) – Bococizumab • Adnectins • Small interfering RNA PCSK9 synthesis inhibitor – Inclisiran (acts in liver) Monoclonal antibodies to PCSK9

Mechanism of action – within the circulation FOURIER Trial - evolocumab

27,564 high-risk, stable patients with established CVD

High or moderate intensity statin therapy (± ezetimibe)

LDL-C ≥1.8 mmol/L or non-HDL-C ≥2.6 mmol/L

Evolocumab SC Placebo SC 140 mg Q2W or 420 mg QM Q2W or QM

Median follow up 26 months An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School Sabatine MS et al. Am Heart J 2016;173:94-101 LDL Cholesterol

100 Placebo 90

80

70 59%LDL-cholesterol mean reduction reduced (95%CI by 1.4mmol/L 58-60), (~60%) P<0.00001 60 All patients on statin therapy Absolute reduction: 56 mg/dl (95%CI 55-57) 50

40

LDL CholesterolLDL (mg/dl) 30 Evolocumab 20 (median 30 mg/dl, IQR 19-46 mg/dl) 10

0 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 Weeks An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School Sabatine MS et al. NEJM 2017; 376:1713-22 Primary Endpoint

16% Hazard ratio 0.85 14.6% 14% (95% CI, 0.79-0.92) P<0.0001 12.6% 12% Placebo Revasc 10% Cor 8% Evolocumab 6% CV Death, MI, Stroke, 4%

Hosp for UA, for Hosp UA, or CVD death, MI, stroke, unstable angina, coronary revascularization 2%

0% 0 6 12 18 24 30 36 Months from Randomization An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School Sabatine MS et al. NEJM 2017; 376:1713-22 Key Secondary Endpoint

10% 9.9% 9% Hazard ratio 0.80 (95% CI, 0.73-0.88) 8% P<0.00001 7.9% Placebo 7%

6%

5%

4% Evolocumab

3% CV Death, MI, or Stroke 2% CVD death, MI, stroke

1%

0% 0 6 12 18 24 30 36 Months from Randomization An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School Sabatine MS et al. NEJM 2017; 376:1713-22 SPIRE trials - bococizumab

SPIRE trials stopped early – bococizumab program stopped

Ridker P et al. NEJM 2017; 376:1527-39 Ridker P et al. NEJM 2017; 376:1527-39 SPIRE trials - bococizumab

Ridker P et al. NEJM 2017; 376:1527-39 Is there a threshold for LDL-c and CVD benefit?

Giugliano R et al. Lancet 2017; 390:1962-71 Safety of very low LDL-c: extreme fifths

Achieved LDL-c Achieved LDL-c P value across all <0.5mmol/L ≥2.6mmol/L groups All SAEs 23% 23% 0.13 AST or ALT >3X ULN 2% 2% 0.19 CK >5X ULN 1% 1% 0.99 New-onset diabetes 8% 8% 0.63 Neuro-cognitive 0.019 2% 1% events (adjusted 0.15) Cataract 2% 1% 0.15 Malignancy 2% 2% 0.22 Non CVD death 1% 1% 0.67

Giugliano R et al. Lancet 2017; 390:1962-71 Summary: monoclonal antibodies to PCSK9

Lessons learned Disadvantages • PCSK9 inhibition reduces • Hassle LDL-c substantially – Injection each 2-4 weeks • Effect on CVD as predicted (self administered) – Storage conditions • Very low LDL-c achieved • Cost – Regardless of statin therapy • Safe • Immune reaction – Bococizumab – Cognition – New-onset DM • Not organ specific – Cancer

Nuffield Department of Clinical Trial Service Unit & Population Health Epidemiological Studies Unit Inclisiran: an inhibitor of PCSK9 synthesis

• Small interfering RNA – Protein synthesis transcribed translated DNA mRNA protein – Specifically reduces hepatic PCSK9 synthesis i.e. ‘at source’ • Given by subcutaneous injection (300mg inclisiran sodium): – Baseline – 3 months – Every 6 months thereafter GalNAc-siRNA conjugates facilitate rapid hepatic uptake Background

GalNAC: N-acetylgalactosamine; ASPGR: Asialoglycoprotein receptor

24 Small interfering RNA (siRNA) targeted to PCSK9 Mechanism of action

RISC: RNA Induced Silencing Complex GalNAc: N-acetylgalactosamine Whitehead et al. Nat Rev Drug Discov 2009;8:129-38 mRNA: messenger RNA 25 Methods ORION-1 trial design

Screened (696)

Stratified by country and Rx One dose start Randomized (501) Two dose start

Placebo 200 mg 300 mg 500 mg Treated (497) Placebo 100 mg 200 mg 300 mg N=65 N=60 N=61* N=65* N=62 N=61* N=62* N=61

Day 1 Study drug given Completed (483) Day 1 Study drug given Day 14 1st follow-up visit Day 14 1st follow-up visit Day 30 Monthly follow-up visits Day 30 Monthly follow-up visits

Day 90 Day 90 Study drug given

Day 180 Primary evaluation Day 180 Primary evaluation

Day 210 End of study visit Day 210 End of study visit

Day 360 Extended follow-up Day 360 Extended follow-up

26 Efficacy: One dose starting regimen—300 mg optimal Robust, sustained LDL-C reductions

300 mg 300 mg 300 mg 50.9% reduction 38.6% reduction 19.0% reduction 10

95% CI) 95% 0 ± -10 P-value for all comparisons to placebo <0.0001 -20

-30

-40 Placebo 200 mg -50

Mean percent change ( 300 mg 500 mg -60 0 30 60 90 120 150 180 210 240 270 300 330 360

Days from first injection

27 Efficacy: Two dose starting regimen—optimal Robust, sustained LDL-C reductions

300 mg x2 300 mg x2 55.5% 52.5% 31.4% 10 Placebo 100 mg 95% CI) 95% 0 ± 200 mg 300 mg -10 P-value for all comparisons to placebo <0.0001 -20

-30

-40

-50 Mean percent change ( -60 0 30 60 90 120 150 180 210 240 270 300 330 360

Days from first injection

28 Inclisiran: summary of available data

Key information Advantages • 300mg • Injection timing • Baseline, 3 months, then – Injection each 6 months every 6 months is the (healthcare professional optimal regimen administered) • 50% average reduction in • Mechanism of action: organ LDL-c specific • Appears safe • 5% injection site reaction

Nuffield Department of Clinical Trial Service Unit & Population Health Epidemiological Studies Unit The role of CETP

CETP – cholesteryl ester transfer protein CETP inhibition CETP inhibitors

WEAK POTENT Dalcetrapib Torcetrapib Evacetrapib Anacetrapib HDL cholesterol +27% +70% +132% +104% Apolipoprotein B 0% -15% -19% -18% Blood pressure ↔ ↑↑ ↔ ↔ CVD outcome trial DalOUTCOMES ILLUMINATE ACCELERATE REVEAL CVD trial size 15,871 15,067 12,092 30,000 CVD trial duration 2.6 years 1.5 years 2.3 years 4.1 years Why stopped? Futility Harm Futility As planned CVD trial HR 1.04 1.25 1.01 0.91 REVEAL trial: design REVEAL – primary outcome Benefit is related to LDL-c reduction Content

• Background • PCSK9 inhibition – Monoclonal antibodies – Small interfering RNA • CETP inhibition • Final word – statin therapy Statins: benefits are substantial, risks are very small

Based on treating 10,000 patients with atorvastatin 40mg daily for 5 years (approximate reduction in LDL-cholesterol 2mmol/L)

Benefit or Risk Number of Patients with Benefit or Harm CVD events prevented (secondary prevention) 1000 CVD events prevented (primary prevention) 500 New onset diabetes mellitus 50-100 Muscle symptoms (uncomplicated) 100 Myopathy (including rhabdomyolysis) 5 Hemorrhagic stroke 5-10 Severe liver disease <1

From multiple landmark randomized trials with 200,000 participants